Role Description Responsible for review of clinical information received from Physicians and other Clinical providers ensuring clinical data is substantial enough to authorize services. Analyzes clinical information to ensure the services requested are authorized according to clinical protocols. Responsible for validation of member benefits for the services requested. Validates accuracy of insurance enrollment information in the system prior to authorizing services. Requires knowledge of managed care contracting, clinical protocols and clinical review requirements. Requires knowledge of regulatory and compliance requirements for government payers, self funded and commercial payers. Ensures appropriate and accurate information is entered into claims system for processing of payment.

Qualifications

• HS - High School Grad or Equivalent (REQUIRED)
• LPN Diploma or Associate Degree in Practical Nursing (preferred)
• Licensed Practical Nurse (LPN) - Nursing License - Compact/Multi-State License (REQUIRED)

Requirements

• Related experience - 3 years
• Health Plan OR Utilization Management experience (preferred)
• JIVA and Milliman Care Guidelines (MCG) experience (preferred)
• Related clinical experience as an LPN, such as experience in a physician office, acute care, managed care or clinic setting, and prior authorization

Benefits

• Medical, Dental, Vision plans
• Adoption, Fertility and Surrogacy Reimbursement up to $10,000
• Paid Time Off and Sick Leave
• Paid Parental & Family Caregiver Leave
• Emergency Backup Care
• Long-Term, Short-Term Disability, and Critical Illness plans
• Life Insurance
• 401k/403B with Employer Match
• Tuition Assistance – $5,250/year and discounted educational opportunities through Guild Education
• Student Debt Pay Down – $10,000
• Reimbursement for certifications and free access to complete CEUs and professional development
• Pet Insurance
• Legal Resources Plan
• Colleagues have the opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria is met.